Occupational Therapy: Activities of Daily Living, Driving, and Community Reintegration

Jennifer Fleming and Deirdre R. Dawson

BACKGROUND

Definitions

• Occupation: Activity that gives structure, value, and meaning and encompasses work (paid and unpaid), leisure, and self-care [1]—includes activities of daily living (ADLs).

• Occupational performance: The doing of activities in the environment in which they need to be done, for example, cooking a meal at home for the family.

• Occupational therapist (OT): Per the World Federation of Occupational Therapy, an OT is a therapist trained to enable people to participate in everyday life by enhancing their abilities and/or by modifying the environment to better support participation.

• Activities of daily living: Functional daily activities generally divided into basic (self-care tasks) and instrumental (everyday activities necessary for interacting with the environment, more complex than basic ADLs). Examples of the latter include using public transport, managing personal finances, meal preparation, and home management. Instrumental activities of daily living (IADLs) are generally understood to exclude work-related activities.

• Driving: The control and operation of a motor vehicle. By law, medical clearance is required following the onset of a medical condition or disability that could affect driving.

• Community integration: “Something to do, somewhere to live, someone to love” [2]. Has three primary constructs: independent living, social support, and productive occupation [3].

Epidemiology

More than five million Americans are estimated to have long-term disability resulting from traumatic brain injury (TBI) [4]. After moderate to severe TBI, most people (95%) regain independence in BADLs, 20% to 30% require assistance for IADLs including domestic activities, shopping, using public transport and financial management, 30% to 50% are unable to drive, and approximately 50% are unable to return to leisure activities, employment, or study [5]. The estimated prevalence of TBI of all severities among offender individuals is 60% and among the homeless is up to 53% [6,7].

ASSESSMENT AND EVALUATION

Step 1

Client-centered goal setting: Collaborative goal setting is critical to identifying key occupational performance issues for each client [8]. It may be necessary, useful, and/or relevant to involve a family member or other caregiver in this interview process.

Step 2

Assessment of specific areas of occupation: Select assessments based on client-centered goals and whether you need an “outcome” measure (for evaluation) or a measure to describe client’s abilities [9]. Important considerations: Do informant and self-reports concur with each other and with actual performance? Does the client use strategies to compensate for impairments in physical and cognitive functions?

• Performance-based measures involve direct observation and provide a more comprehensive and accurate picture of strengths and weaknesses. Performance is influenced by the environment and determining performance is best achieved in the client’s own environment [10]; this will provide more ecological validity (i.e., performance on the test corresponds to an everyday situation).

• Consider The ADL and IADL Profile [11,12], which provides for comprehensive measures of ADLs, and the impact of executive dysfunction on everyday life, or the Multiple Errands Test [13], which allows observation of strategies employed while shopping and collecting information.

• Questionnaires—typically provide information about capability but not performance [14]

BADL and IADL—many available [14].

Community integration: Self-report or informant report. The Community Integration Questionnaire (www.tbims.org/combi), Reintegration to Normal Living Index [15], and Sydney Psychosocial Reintegration Scale [16] are psychometrically sound and clinically useful.

Step 3

Special areas for consideration:

• Cognition (see also Chapters 33 and 35): OTs assess cognition particularly as it relates to everyday life (e.g., safety with household ADLs, planning daily activities, remembering to take medication and attend appointments, navigating in the community).

• Driving assessment: A comprehensive multidisciplinary assessment, inclusive of an off-road assessment of visual, sensory, cognitive, and physical function and an on-road test, is critical in moderate to severe TBI [17,18]. Decisions regarding driving ability are based upon not only medical fitness but the functional abilities required for safe driving, which are determined using a combination of off-road and on-road assessment. Cognitive performance alone does not predict driving capacity [19]. A comprehensive driving evaluation is considered the gold standard to assess fitness to drive [18] and is administered by a trained OT [17]. The timing of on-road assessment is individual and occurs when sufficient recovery has occurred for medical clearance to be a realistic outcome. Conducted in a dual-control vehicle, it usually follows a standardized route and set of maneuvers. One measure used is the Driver Observation Scale (DOS), which records driver behavior in the traffic environment and appropriateness of maneuvers performed [20]. The Association for Driving Rehabilitation Specialists provides information on specialized testing and training services across North America (www.driver-ed.org). The few studies investigating whether people with TBI who return to driving have more accidents than healthy controls have produced mixed results [21]. Driving is a complex IADL that is linked to autonomy, self-identity, and community access, and is considered a rite of passage to adulthood, making it a focus for rehabilitation for many patients with TBI.

• Return to work and school—see Chapter 69.

• Social support, social integration, and sexuality: Reductions in social support, social isolation, relationship breakdown, and negative changes in perceived sexuality are frequent outcomes [20] and need to be considered in a comprehensive assessment of community integration. (See also Chapter 41.)

INTERVENTION

Five key areas to consider: regaining functional independence (BADLs and IADLs), social support and community integration, housing, driving and transportation, and ongoing community participation. Participation in meaningful life situations is the goal, and gains can be achieved many years post injury [22].

A. Regaining functional independence.

• Comprehensive rehabilitation programs that focus on (1) integration of therapies, (2) metacognition (i.e., self-awareness and comprehension of one’s thinking processes), (3) self-regulation, and (4) participating in personally meaningful life activities have better outcomes than neuropsychological rehabilitation alone [23].

External strategies to compensate for cognitive impairments (schedules, checklists, routines, smartphone calendar and alarm functions, memory notebooks, whiteboards, and personal digital assistants) are recommended as effective for clients with severe TBI [22].

Individualized strategies should be selected on the basis of client goals, preferences, and abilities, and taught using techniques such as errorless learning, spaced retrieval, and distributed practice with the involvement of family members [24].

Internal strategies (e.g., visualization/visual imagery) are effective for clients with mild to moderate TBI [24].

Metacognitive strategy instruction is recommended for adults with TBI with executive dysfunction [25], and “should be focused on everyday problems and functional outcomes” ([25], p. 343). Such instruction includes “acknowledging or generating goals, self-monitoring and self-recording of performance and strategy decisions based on performance-goal comparison” ([26], p. 37).

Direct feedback on occupational performance delivered in the context of a therapeutic program is effective for improving occupational performance and level of self-awareness [25,27].

• For severely impaired survivors, improving performance on selected skills may be achieved by specific functional skills training [26,28] comprising task analysis, written prompts, embedding retrained skills in programming, consistent practice, and fading cues. Independence in any particular skill can take months to achieve, and as benefits are often not generalizable; therefore, the cost vs. benefit should be evaluated carefully.

B. There is currently limited social support, social integration opportunities, and interventions to enhance positive expressions of sexuality.

• Multi-faceted social support groups that focus on education, coping-skills training, and goal setting may reduce hopelessness and engender a greater sense of control [22].

• Social-skills training, including individualized goal setting, shaping of behaviors, and social perception training, may improve specific aspects of social behavior [29,30].

• Peer mentoring may improve social participation [22].

• Family support and education may be necessary to assist family members to manage neurobehavioral changes after brain injury and adjust to relationship changes [31].

C. Housing: OTs should provide input to team members regarding level of independence so appropriate housing can be arranged. This may include the prescription of home modifications to increase safety and independence.

D. Driving and transportation: Access to transportation is a key for community integration. Driving rehabilitation may include computer-based training, off-road skill specific training and education, and on-road driving remediation. The evidence of effectiveness for improving fitness to drive is limited [32]. Thus, in addition to careful assessment of return to driving, public transportation should be considered as an alternative. As its use is cognitively complex, assessment and training may be required.

E. Community participation: Emerging research evidence and considerable anecdotal data suggests the value of community-based support programs for enhancing community participation even many years post TBI [33,34]. Important components appear to be (1) a long-term approach, (2) individualized goal clarification, and (3) therapy in the person’s own environment.

• Treatment environment:

Multidisciplinary rehabilitation programs improve overall community integration [33].

Participants in community-based day programs report long-term emotional, social, and cognitive benefits [35] and better social participation and quality of life than those who are assessed as eligible but do not attend [36].